Single-Payer or Bust

In the 1960s, a struggle took place over the fate of healthcare in Canada. On one side, there were the proponents of the single-payer program called Medicare, like the stubborn Scottish-born socialist Tommy Douglas. Medicare was modeled on a program passed in the province of Saskatchewan in 1961 under Douglas’s leadership, which provided universal coverage of physicians’ services (the province’s 1947 plan for universal hospital coverage had already been federalized in the late 1950s). And on the other side there were those who advocated a more gradual approach, such as Ernest Manning, the premier of Alberta, who went on television in 1965 to ask the nation to “look before we leap.” After all, the Saskatchewan program—funded by premiums and a slew of new taxes—had been implemented only after a bruising physicians’ strike, which ended only after twenty-three bitter, dangerous days that made international headlines. And that was just in one snowy, sparsely populated province—this was what Douglas was now demanding for the entire nation.

It wasn’t that Manning was opposed to expanding healthcare access. On the contrary, he reassured listeners that he was “100 percent in support of the proposition that high quality comprehensive medical services should be available to every citizen whether his income be large or small.” But, as a 1995 article in Alberta History described, he had philosophical differences with Douglas’s approach: he thought it neglected the importance of personal responsibility. Manning also foresaw practical problems with the Saskatchewan model. It would necessitate unpopular new taxes for all of Canada, while its lack of cost-sharing (that is, co-payments) would, he feared, encourage excess healthcare use. Its implementation would also require that existing medical insurance programs and the companies providing them be eliminated, a move he considered “unwise and unwarranted.”

Nor was single-payer the only option. In 1963, Manning had introduced a more incremental healthcare reform in Alberta, dubbed “Manningcare,” that achieved results, and which he thought could serve as a better, less disruptive model for the nation. “Like Obamacare,” wrote Canadian healthcare expert Greg Marchildon in 2016, “[Manningcare] . . . involved multiple tiers of coverage above a basic plan . . . and eschewed single-payer financing in favour of multi-payer administration through numerous private insurance carriers.”Private insurance would be expanded via public subsidization, while out-of-pocket payments—like co-payments—would be retained. Alberta had notable success in broadening coverage this way—achieving 80 percent coverage of the population—as Marchildon and Nicole O’Byrne note in Making Medicare: New Perspectives on the History of Medicare in Canada (2012).